10.09.67.01. 01 Required Benefits Package ― In General.. A. Except for non-covered services set forth in Regulation .27 of this chapter and the non-capitated services described in COMAR 10.09.70, an MCO shall provide its enrollees with a benefits package that includes the covered services specified in this chapter when these services are deemed to be medically necessary including services covered under the Maryland Medicaid State Plan in the amount, duration, and scope set fort

10.09.67.02. 02 Benefits ― Primary Care Services.. An MCO shall provide to its enrollees medically necessary primary care services that are provided:. A. By the enrollee's PCP;. B. At the direction of the enrollee's PCP; or. C. With respect to a primary care service that is self-referred pursuant to Regulation .28 of this chapter:1) By an appropriate practitioner, acting within the scope of the practitioner's license, certification, or other legal authorization, and in accordan

10.09.67.03. 03 Benefits ― Physician and Advanced Practice Nurse Specialty Care Services.. A. An MCO shall provide to its enrollees medically necessary specialty care services that are outside of the enrollee's PCP's scope of practice, or, in the judgment of the enrollee's PCP, are not services that the PCP customarily provides, is specifically trained for, or is experienced in and are provided by:1) A physician or an advanced practice nurse, acting within the scope of th

10.09.67.05. 05 Benefits ― Home Health Services.. A. Subject to the conditions specified in §B of this regulation, an MCO shall provide to its enrollees medically necessary home health services, including:1) Skilled nursing services, including the supervisory visits required by §A(2) of this regulation;. 2) Home health aide services, including biweekly supervisory visits by a registered nurse in the recipient's home, every second visit of which includes observations of the del

10.09.67.07. 07 Benefits ― Inpatient Hospital Services.. A. An MCO shall provide to its enrollees medically necessary inpatient hospital services as specified in this regulation.B. Admission to Long-Term Care Facility.. 1) An MCO shall provide to its enrollees medically necessary long-term care facility services for:. a) The first 90 continuous days following the enrollee's admission; and. b) Any days following the first 90 continuous days of an admission until the date the MCO has obtain

10.09.67.12. 12 Benefits ― Long-Term Care Facility Services.. A. An MCO shall provide to its enrollees medically necessary services in a chronic hospital, a chronic rehabilitation hospital, or a nursing facility for:1) The first 90 continuous days following the enrollee's admission; and. 2) Any days following the first 90 continuous days of an admission until the date the MCO has obtained the Department’s determination that the admission is medically necessary as specified in §C of th

10.09.67.13. 13 Benefits ― Disposable Medical Supplies and Durable Medical Equipment.. A. An MCO shall provide to its enrollees medically necessary disposable medical supplies and durable medical equipment, including but not limited to:1) All supplies and equipment used in the administration or monitoring of prescriptions by the enrollees; and2) Incontinency pants and disposable underpads for medical conditions associated with prolonged urinary or bowel incontinence if necessary to prevent

10.09.67.14. 14 Benefits ― Vision Care Services.. A. An MCO shall provide to its enrollees medically necessary vision care services as specified in this regulation.B. For enrollees who are 21 years old or older, the MCO is responsible for providing at least one eye examination every 2 years.C. For its enrollees who are younger than 21 years old, the MCO is responsible for providing medically necessary vision services, including but not limited to:1) At least one eye exami

10.09.67.19. 19 Benefits ― Family Planning Services.. A. An MCO shall provide to its enrollees comprehensive family planning services, including but not limited to medically necessary office visits and laboratory tests, all FDA-approved contraceptive devices, methods, and supplies, and voluntary sterilizations.B. An MCO may place appropriate limits on family planning services for the purpose of utilization control, provided that the services are provided in a manner that protects an

10.09.67.20. 20 Benefits ― EPSDT Services.. A. An MCO shall provide, to enrollees younger than 21 years old, medically necessary Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) services, including:1) EPSDT comprehensive well-child services provided in accordance with the EPSDT periodicity schedule and performed by an EPSDT-certified provider, including:a) A comprehensive health and developmental history, including an evaluation of both physical and mental health development;

10.09.67.21. 21 Benefits ― Pregnancy-Related Services.. A. An MCO shall provide to its pregnant and postpartum enrollees medically necessary pregnancy-related services, including:1) Comprehensive prenatal, perinatal, and postpartum care, including high-risk specialty care when appropriate;2) Prenatal risk assessment and development of an individualized plan of care that specifies the actions required to address each identified need and is appropriately modified during the course of care;

10.09.67.23. 23 Benefits ― Hospice Care Services.. A. An MCO shall include in its benefits package medically necessary hospice care services to enrollees who are terminally ill.B. The Department shall allow an enrollee to disenroll from an MCO and choose a new MCO if:. 1) The enrollee was auto-assigned to the MCO; and. 2) The enrollee's hospice provider does not contract with the enrollee's assigned MCO.. C. If an enrollee who is in a hospice that does not contract with the enrol

10.09.67.24. 24 Benefits ― Diabetes Care Services.. A. An MCO shall provide to its qualifying enrollees medically necessary diabetes care services as specified in this regulation.B. In addition to the services included in its usual benefits package, an MCO shall provide enrollees with a diabetes diagnosis the following medically necessary special diabetes-related services:1) Diabetes nutrition counseling, consisting of one initial one-on-one session and up to 4 subsequent sessions annually;

10.09.67.26-1. 26-1 Clinical Trial Items and Services ― Coverage for Routine Costs.. A. Subject to the conditions specified in §B―F of this regulation, an MCO shall provide coverage for cost to an enrollee in an approved clinical trial for:1) Treatment provided for life-threatening conditions; or. 2) Prevention, early detection, and treatment studies on cancer.. B. Clinical trials are deemed to be automatically approved if:. 1) The treatment is:. a) Being provided or the

10.09.67.27. 27 Benefits ― Limitations.. A. The benefits or services not required to be provided by an MCO are as follows:. 1) Experimental or investigational services, including organ transplants determined by Medicare to be experimental, except when an enrollee is participating in an authorized clinical trial as specified in Regulation .26-1 of this chapter;2) Any service or treatment that is not medically necessary;. 3) Services performed or prescribed under the direction of a person who is

10.09.67.28. 28 Benefits ― Self-Referral Services.. A. An MCO shall be financially responsible for reimbursing, in accordance with COMAR 10.09.65.20, an out-of-plan provider chosen by the participant for the following services:1) Family planning services specified in COMAR 10.09.65.20A(2) (6) and (7). 2) Services performed by school-based health centers (SBHCs) as provided in COMAR 10.09.76;. 3) Pregnancy-related services for women who are pregnant and, at the time of initial enrollment, hav

10.09.67.29. 29 Optional Services.. A. An MCO may provide its enrollees with additional health care services that are not required by this chapter.B. Optional health care services that an applicant intends to include in its benefits package shall be specified, including the terms and conditions for, and limitations to the provision of these services, in the applicant's initial application to the Department, as well as for periodic Departmental review.C. An MCO's provision of